Sequential Application of Transpupillary Thermal Therapy and Cryotherapy in the Management of Small Choroidal Melanoma: A Pilot Evaluation of Efficacy and Safety

Purpose: To evaluate whether transpupillary thermal therapy and cryotherapy could improve control of small choroidal melanoma and reduce scleral extension risk. Methods: A retrospective review identified 30 patients with clinically diagnosed unilateral choroidal melanoma treated sequentially with transpupillary thermal therapy and cryotherapy between 2001 and 2025. Data collected included demographics, tumor characteristics, treatment response, complications, visual acuity, metastasis, and mortality. Treatment failure was defined as the need for brachytherapy or enucleation. An exploratory comparison with a 2008 study of transpupillary thermal monotherapy was performed. Results: All tumors (100%) showed growth prior to treatment. Mean tumor thickness was 1.63 mm (range, 0.50–2.80 mm), and maximum basal linear diameter was 7.80 mm (range, 5.00–12.00 mm). The mean follow-up was 5.80 years. Tumor regression was achieved posttreatment in 97% of cases; 1 patient required brachytherapy. All-cause mortality was 10%, with 1 patient experiencing death from metastatic melanoma. Compared with the 2008 transpupillary thermal monotherapy study (24% treatment failure rate, 32% complication rate, 8% extraocular extension), the current series demonstrated a 3% treatment failure rate, 53% complication rate, and no intrascleral or extrascleral extension. Macular pucker was the most common complication, occurring in 53%. Conclusions: Sequential transpupillary thermal therapy and cryotherapy may provide effective tumor control for small choroidal melanoma. Sequential transpupillary thermal therapy with cryotherapy was associated with low rates of treatment failure and scleral extension. However, the cohort also had relatively high complication rates for conditions such as macular pucker, vascular occlusion, and refractory cystoid macular edema. Further investigations with larger sample sizes and longer follow-up are warranted to assess the safety and efficacy of sequential transpupillary thermal therapy with cryotherapy.